RESEARCH Open Access PTSD, depression and anxiety among former abductees in Northern Uganda Anett Pfeiffer * and Thomas Elbert Abstract Background: The population in Northern Uganda has been exposed to extreme levels of traumatic stress and thousands abducted forcibly became rebel combatants. Methods: Using structured interviews, the prevalence and severity of posttraumatic stress disorder (PTSD), depression and anxiety was assessed in 72 former abducted adults, 62 of them being former child soldiers. Results: As retrospective reports of exposure to traumatic stress increased, anxiety and PTSD occurrence increased (r = .45). 49% of respondents were diagnosed with PTSD, 70% presented with symptoms of depression, and 59% with those of anxiety. In a multiple linear regression analysis four factors could best explain the development of PTSD symptoms: male respondents (sex) living in an IDP-Camp (location) with a kinship murdered in the war (family members killed in the war) and having experienced a high number of traumatic events (number of traumatic events) were more likely to develop symptoms of PTSD than others. In disagreement to a simple dose- response-effect though, we also observed a negative correlation between the time spent with the rebels and the PTSD symptom level. Conclusions: Former abductees continue to suffer from sev ere mental ill-heal th. Adaptation to the living condition of rebels, however, may lower trauma-related mental suffering. Background Humans are developing in a co-constructive way whereby the biological-genetic interface interacts with the cultural setting to form mind and brain and with it the potential for mental malfunctioning. Traumatic stressors evoke an alarm response, i.e., activate stages in a genetically prepared biologic al defence mechanism that thus appears in any culture. Research into the neu- robiological foundations of traumatic experie nces [1,2] and data reporting similarity in trauma-related symptom profiles across d ifferent cultural settings [3-5] suggest that posttraumatic stress disorder (PTSD) and depres- sion are possible ways of conceptualising mental suffer- ing in response to traumatic stress experiences. Thereby, the cumulative exposure to traumatic experiences, espe- cially when event types vary, seems to have a potentially devastating consequence for mental health, [6-9,4,10-13], probably because the exposure to varying types of stressors is particularly powerful to enlarge the fear network [14]. In the age of “ new wars” [15], even civilians living in crisis regions are affected by organised violence and human rights violations and often have experienced and witnessed a whole trauma pa ckage. Data of Neuner and colleagues [16] for instance, indi- cate that a two-dozen of traumatic experiences is suffi- cient to traumatise 100% of any exposed sample. War background In the Northern provinces of Ugand a, since 1986, there has been a brutal and un relenting war, led by a rebel army that named itself the Lord’ sResistanceArmy (LRA). For 17 years members of the LRA have killed or mutilated t housands of innocent civilians and a signifi- cant proportion of children have been abducted. According to our own surveys in the camps of internally displaced people (IDP) in Gulu and Kitgum districts, nearly every other boy has been abducted, sometimes only for a few days, to help carry the stolen goods to the bush. Through analysing a database of more than 25.000 children who had been registered in a reception centre after returning from captivity, it can be estimated * Correspondence: anett.pfeiffer@uni-konstanz.de Department of Psychology, University of Konstanz, Box D23, 78457 Konstanz, Germany Pfeiffer and Elbert Conflict and Health 2011, 5:14 http://www.conflictandhealth.com/content/5/1/14 © 2011 Pfeiffer and Elbert; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/l icenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original wor k is properly cited. that 25.000 up to 38.000 childre n have been abducted between 1986 and 2006 with an average abduction time of 342 days [17]. Many of the young boys, however, have been forced to stay for years, being abused as child combatants while girl child soldiers are regularly abused as sexual slaves [18]. The fear of being terrorised or caught up in the fighting between the LRA and the Ugandan army has caused most of the people to seek refuge in insecure camps wi th little food and poor sani- tation (IDP camps). At the time of the present investiga- tion, about 1,4 million people have been displaced in the affected areas of Northern Uganda. At that time , thou- sands of people, mainly women and children, marched into the towns and camps seeking shelter, for fear of abduction if they remained in their homes. ThemajorityofIDPs,currentlysettledinthecoun- try’ s northern emergency camps, has suffered or wit- nessed at least one, o ften several, traumatic experiences. The percentage is especially high within the group of formerly abducted children and young adults. Trauma- related illness compromise vital functioning and thus severely interferes with the ability of refugees and forced migrants to cope with the misery in IDP camps and also limits the ca pability in rebuilding their homes and lives, regaining ownership and dignity [19]. A cross-sectional epidemiological study done by Roberts [20] among adults living in IDP-camps in Northern Uganda show a high exposure to traumatic war experiences resulting in 54% of PTSD and 67% depression, even with a higher risk among women. Cor- relating data of Klasen et. al [21] of a strong relationship between traumatic exposure and mental health o ut- comes could also be found among formerly abducted children. Two other studies b oth with children still residing in a reception centre showed simi lar results in trauma exposure and trauma-related responses: up to 10 respectively 11 traumatic war experiences were leading to 35% r esp. 38% of moderately to severely traumatic reactions in respect to PTSD [22,23]. Judith L. Herman [24] had defined complex traumatic exposure as be ing severe i n its nature, continuing repeatedly over a long period of time and with an onset during the person’s childhood. All of these criteria obviously apply to the experiences of formerly abducted children and young adu lts. In the present investigation we wanted to further study the severity and frequency of trauma-related mental suffering, p articularly of t hose who have been abducted and specify the relationship between length of abdu ction as a measure of cumulative trauma e xposure and mental h ealth. Methods Subjects In May and June 2005, 72 interviews were performed with formerly abducted persons of the Gulu district in Northern Uganda. A minimum of 17 yea rs of age was required for participation. The medium age was 23.7 years. The sample (n = 72) was recruited from two dif- ferent locations: 42 respondents (20 female) were living at the time of interview in a Reception Centre (RC), having only escape d the rebel movement within the last few weeks. Thirty persons (11 female) living in IDP- camps participated in a follow-up program. The partici- pants were randomly selected from a complete list of persons living in the reception centres at the moment of the study and from a list of people who had already returned home to the IDP-camp after leaving the recep- tion centre (former beneficiaries of the reception cen- tres). Almost all participants belonged to the ethnic group of the Acholi (94% ) and all completed the full interview. Level of education was signif icantly lower for women than for men, with a third (32%) of the female sample having no education a t all. In co ntrast, ne arly two third of the men (61%) had at least a primary education. Men were abducted significantly more often than women, whereas abduction duration was significantly longer than for girls than for the boys (average of 7.7 years vs. 4.9 years). There was no significant difference between the different interview locations (Reception Centre vs. IDP-Camps) for any of the demographic variables. Instruments The questionnaire included a consent form, socio-demo- grap hic questions about the person, his/he r family, edu- cational level, ethnicity, religion, socioeconomic information, abduction time, trauma experiences, chronic diseases and physical conditions. Traumatic event types we re ass essed using a checklist consisting of possible non-war related traumatic event types (forced marr iage, witnessing suicide, flood, etc.), war related events (witnessing or experiencing injury by weapon, experiencing an ambush or combat situation, etc.) and LRA-specific traumatic event types (abduction, beatings, torture, forced to beat to death, sexual slavery, forced to maim ot hers, etc.). The checklist was partly taken from t he survey “Demography of forced migra- tion” assessed among Sudanese and Ugandan Nationals in the West Nile region [6,16] and compiled by inter- viewing local victims of the LRA-rebels in order to receive information about their unique atrocities against the civilian population. Events included 19 experienced events, eight witnessed events and three events as forced perpetrator. PTSD was assessed using an interview Acholi version (Luo language) of the interview form of t he Posttrau- matic Stress Diagnostic Scale (PDS) [25]. The PDS or its interview form (PSSI) is a widely-used screening instru- ment for diagnosis and severity of PTSD based on the Pfeiffer and Elbert Conflict and Health 2011, 5:14 http://www.conflictandhealth.com/content/5/1/14 Page 2 of 7 17 DSM-IV criteria. Translations in other languages as well as the use in other cultures has been extensive [16,26-28]. The used Acholi version has been also vali- dated for the Luo language within the Acholi culture [29]. For the assessment of depression and anxiety the 25 itemsfromtheshortversionofthe“Hopkins Symptom Checklist” (HSCL-25) was used [30]. This screening instrument assesses ten anxiety symptoms and 15 depression symptoms. The scale has been translated in other languages [31,32] and applied in refugee popula- tions [13,33-37]. To identify ca ses of depression a cut- off score of 1.75 has mostly been used [31,32,20,12]. In a later study, Mollica et al. [38] changed to a scoring algorithm by introducing a DSM-IV based scoring sys- tem. Bolton et al. [39] further adapted and refined this algorithm for a study in Rwanda. The questionnaire for this assessment was translated from the original English version into the local language Luo using the blind back-translation method by Flana- gan [40]. The initial translation was accomplished by two trained screeners, thus the translators were not only knowledgeable about local expressions of psychological suffering, but also abou t clinical diagnostics , procedures and concepts. Informed consent was obtained using a standardised form explaining the potential risk of participation and explaining that no compensation would be provided. Informed consent forms were signe d by the i nter preters assuring that s/he has read everything to the respondent and s/he did fully understand their rights. No financial incentives were provided and respondents were informed that no improvements in living condition s were to be expected as a result of participating in the survey. The study was approved by the Konstanz Uni- versity Ethical Review Board and took place in coopera- tion with the World Vision Reception Centre for children, for men and child mothers. Results All interviewees had been abducted by LRA rebels and all of them have experienced a series o f different trau- matic event types, (average 16.5 SD 2.7, from 26 possi- ble event type catego ries (see Figure 1); table 1 presents an overview of traumatic events that more than 70% of all respondents have experienced or witnessed. Almost half of all respondents (49%) were diagnosed with PTSD meeting the DSM-IV criteria. Data indicate Figure 1 Average load of traumatic event types by event type category and gender. Table 1 Traumatic events (experienced or witnessed) by more than 70% of the respondents Frequency in % (n = 72) combat situations (armed attacks, ambushes, fighting, crossfire) 99 being forced to fight (with firearms against UPDF or SPLA) 85 witnessing killing or murder (shot during combat, beaten to death, hacked to death with pangas, axes, sticks or knives) 97 witnessed gunshot wound during combat 99 beatings with sticks, logs or pangas for punishment or initiation rituals 93 witnessed beatings 94 witnessed abduction of a first grade family member** 90 witnessed mutilations 82 being forced to carry heavy loads with threat of death for dropping 94 being threatened to death (e.g. for failed escape attempts) 94 fear of starving or dying of thirst 92 sexual abuse by a stranger (incl. rape, attempted rape, “given as wife” to a LRA rebel commander, being raped by UPDF) 97* giving birth of a child during abduction (with beatings for screaming and no midwifery assistance) 74* * only percentage of women (n = 31) ** First grade family members are those who are either directly related by blood in the first degree (parents, children, siblings) or related by marriage (husband, wife). We choose this definition in order to obtain valid data on the status of the immediate affected family members. Pfeiffer and Elbert Conflict and Health 2011, 5:14 http://www.conflictandhealth.com/content/5/1/14 Page 3 of 7 that the preval ence of PTSD is higher in the IDP camps than when still in the reception centre. Such an effect is not observed for the women (see table 2). The depression cut-off score for clinical relevance was reached by 71% of the interviewees and for anxiety by 60%. More than a third of the respondents (36%) fulfil the criteria for all three ascertained mental health disor- ders simultaneously. The total amount of trauma event types correlates sig- nificantly with the PTSD sum score (r = .45, p < 0,001; Figure2).LookingonlyatLRA-specifictraumaevent types, meaning traumatic events that are specifically cruel and unique to the war in Northern Uganda (e.g. witnessed mutilations of lips, ears, noses), and events that describe actions where the person was forced to become a perpetrator and to harm others, also produced significant positive correlations (r = .33, p < .01 and respectively r = .28, p < .05). I n addition, the more family members (first grade only) had been killed during the violent clashes the higher the PTSD symptom sum score (r = .24, p < .05). None of the above-mentioned factors, which correlate positively with the posttraumatic symptoms, correlate with the depression symptoms. The age at t he fi rst time of abduction does not corr e- late with the posttraumatic symptom score (.056, n.s.). Unexpectedly and in contrast to an e xpected dose- or “ building-block"-effect [16] of exposure to traumatic stress, the duration of the abduction time spent in bush correlates negatively with the PTSD symptom sum score (see Figure 3; r = 28, p < .05), meaning that the longer a person was abducted, the fewer symptoms were reported. Using a multiple linear regression, four factors can best explain the PTSD symptom sum score as depen- dent variable (see table 3): the t otal number of types of traumatic stressors experienced, the locatio n of living at the time of the interview (Reception Centre vs. IDP- Camp), the amount of killed family members and the sex of the respondent (corrected r-square: .409, F = 13.28, p < .001). In other words: male respondents living in an IDP-Camp with a kinship murdered in the war and having experienced a high number of traumatic events were more likely to develop symptoms of PTSD than others. Discussion The war-affected and formerly abducted y oung women and men from Northern Uganda who have been inter- viewed in this study are suffering from severe mental health cons equences of the trauma-spectrum disorders (49% diagnosed with PTSD, 71% with symp toms of depression, 60% with those of anxiety) resulting from a high number of experienced traumatic events (in average 16.5 traumatic event types per person). The reported atrocit ies that more than 70% of the inter viewees experi- enced (see Table 1) took place during the interviewees’ forced abduction time with the rebels of the Lord’s Resis- tance Army (LRA) and they quantify descriptions of atro- cities documented by human rights reports [41]. The interviewed sample shows to be highly affected by traumatic war experiences and their consequences: almost every other person suffers from PTSD. Similar psychodiagnostic results can also be found in other stu- dies conducted in Northern Uganda [20,21,42] or simi- larly war torn regions over the world [9,43-45]. PTSD, however, is not the only psychiatric condition that may develop in the aftermath of trauma. On the contrary, comorbidity is the norm rather than the exception. Breslau [46] for example, found that 83% of her PTSD sample met criteria for at least one other psy- chiatric disorder, compared with 44% of those without PTSD. The National Comorbidity Survey [47] reported that 88% of men and 79% of women with chronic PTSD met criteria for at least one other psychiatric diagnosis. In each of those studies, major depression was found to be one of the most prevalent conditions o ccurring con- currently with PTSD. Table 2 PTSD Diagnosis in percentage (%) BY LOCATION RC* (n = 42) IDP-camp** (n = 30) Total (n = 72) BY GENDER Men (n = 41) 36 68 51 Women (n = 31) 45 45 45 Total (n = 72) 40 60 49 * Reception Centre ** Internally displaced persons camp Figure 2 Scatter plot of the number of traumatic event types and the PTSD symptom sum score with fitted linear regression line. Pfeiffer and Elbert Conflict and Health 2011, 5:14 http://www.conflictandhealth.com/content/5/1/14 Page 4 of 7 Also the present interviewed sample is not only highly affected by PTSD but shows high symptom scores of depression a nd anxiety. Evenly high rates of depression were also found in similar war-torn regions, for example among Cambodian refugees with a comparable experi- ence of traumatic events: Carlson & Rosser-Hogan [33] found a rate of 86% PTSD and 80 % of clinical depres- sion. This has been equally found for the comorbidity between PTSD and anxiety [13]. There is a significant positive correlation between the amount of experienced traumatic event types and the prevalence of a PTSD. This is coherent with other stu- dies investigating the consequences of organised vio- lence [10-12]. Also the correlation between the exposure to traumatic stressors and symptoms of PTSD is highe r than the correlation between traumatic event load and symptoms of depression, since the presence of at least onetraumaticeventisnotonlyaprerequisiteforthe diagnosis of PTSD, but als o the existence of a dosage relationship has been shown [45,48-50]. Since the amount of traumatic event types is a good predictor for the severity of the symptoms, the specified dose effect can be confirmed. Again, this is consistent with refugee studies from war regions [12,13,45]. If one looks at different levels of traumatisation, the severity of traumatic events can be described using dif- ferent characteristics such as age of first traumatic event, the intentionality of an event (natural cata- strophes vs. human-made deliberate, violent actions), and the duration respectively the re-occurrence of events. As for the t raumatic events experienced by the present sample of this study, the classic definition for complex traumatic events postulated by Judith L. Her- man [24] seems to well fit their nature as they fulfil all criteria of this definition: The reported traumatic experi- ences can be rated as highly traumatic due to their vio- lent and cruel nature; they take place over a long period of time (medium duration of abduction: 6 years); they happened repeatedly to the abductees (many of the trau- matic events were part of their daily lives); and the interviewees were in average only 14 years old at the time of their first abduction. The experience of trau- matic event types, which are infamous for their cruelty and thus severity of traumatic experience (LRA-specific events, events of forced perpetrators and the loss of first grade family members) correlate - in accordance to this definition - positively with the score of posttraumatic symptoms. However none of the other factors - for which it was possible to be ascerta ined in this study - correlate positively or at all with the posttraumatic stress symptoms. The total amount of experienc ed trau- matic even ts has not been asked for, as it is dif ficult or impossible for the interviewees to remember and to count for how often a certain event took place over a period of years. The age at the first time of abduction shows no correlation with the posttraumatic symptoms. Surprisingly, the duration spent in abduction is corre- lating negatively with the sum score of the PTSD symp- toms. The longer a person is abducted, the lower the sum score of the symptoms gets, but still within a clini- cal significant range. One poss ible explanation would be that those who have greater symptoms are more likely to be killed in the bush, or more likely to es cape. While we cannot completely rule out this possibility, it would require that fatalities were even higher than the worst estimates. Obviously, survivors who stayed in the bush have adapted to this life with some resilience against PTSD. This adaptation can be argued as a protective and coping mechanism of denial of ongoing horrifying events. Elbert, Weierstall and Schauer [51] though have argued that becoming a perpetrator can be appetitive behaviour disconnecting many of the cues, like for instance “blood” from the neural fear network as they become associated with the fascination for violence and hunting - humans in this case. This pruning of the fear network may result in a decreased vulnerability for PTSD, as has been suggested by recent work [52]. Conclusions Even though the sample is limited and not representa- tive for the population of Northern Uganda, it can be Figure 3 Scatter plot of the tota l time of abduction in years and the PTSD symptom sum score with a fitted linear regression line. Table 3 Multiple linear regression with the dependent variable of the PTSD sum score Model r r-square corrected r-square Statistic p 1 .665 .442 .409 F = 13.28 < 0.001 Model 1 - Controlled variables: total amount of all traumatic event types, location, amount of killed family members, sex Pfeiffer and Elbert Conflict and Health 2011, 5:14 http://www.conflictandhealth.com/content/5/1/14 Page 5 of 7 shown that children in Northern Uganda - at the time of abduction (mean age of first abduction: 14 years), now youth and young adults (mean age at time of inter- view: 24 years) - are like other children, youth and adults living in war affected areas are highly affected by the mental health consequences resulting from their vio- lent, cruel and life-threatening traumatic experiences during the war. The psychological suffering of produc- tive symptoms like acted-out flashbacks and active avo idance or “quiet” symptoms like intrudi ng memori es or feelings of loneliness thus leads to dysfunctional behaviour in daily routine tasks, social life and work/ scholastic life (as dysfuncti onality is one criterion to diagnose PTSD). Therefore they a re in need of mental health interventions to relieve them from their suffering and make them functional again for their personal daily life tasks as well as in the interest of a society trying to recover from years of insurgencies. As an interesting tendency that this study’s result have shown is the decrease of posttraumatic stress symptoms after a longer time spent in the bush. Although other studies have not found this negative relationship [17] - as this might indicate a survival mechanism, more research is needed in order to find out more about this possibly protective mechanism, whether it can interme- diately protect from posttraumatic stress symptoms or may result in other not in this study asked for mental health disorders. Therefore further research is needed on a bigger sample to see if results can be replicated either way. But the focus should not only be on the out- come, but also on the predisposition to this phenomenon. Acknowledgements Research was supported by the DFG and made possible by the NGO vivo http://www.vivo.org. Authors’ contributions AP designed the study, collected the data, performed the statistical analyses and drafted the manuscript. TE supervised the design of the study and the work. All authors participated in revising the manuscript, and have read and approved the final version. Competing interests The authors declare that they have no competing interests. Received: 24 March 2011 Accepted: 26 August 2011 Published: 26 August 2011 References 1. McFarlane AC: The prevalence and longitudinal course of PTSD: implications for the neurobiological models of PTSD. Ann NY Acad Sci 1997, 821:10-23. 2. Southwick S: Psychological and neurobiological consequences of the Gulf War experience Springfield: NTIS; 1999. 3. Sack WH, Seeley JR, Clarke GN: Does PTSD transcend cultural barriers? A study from the Khmer Adolescent Refugee Project. JAACAP 1997, 36(1):49-54. 4. Mollica RF, McInnes K, Pham T, Smith Fawzi MC, Murphy E, Lin L: The dose- effect relationships between torture and psychiatric symptoms in Vietnamese ex-political detainees and a comparison group. J Nerv Ment Dis 1998, 186(9):543-553. 5. Elbert T, Schauer M: Burnt into memory. Nature 2002, 419:883. 6. Karunakara U, Neuner F, Schauer M, Singh K, Hill K, Elbert T, Burnham G: Traumatic events and symptoms of post-traumatic stress disorder amongst Sudanese nationals refugees and Ugandan nationals in the West Nile. African Health Sciences 2004, 4(2):83-93. 7. Kolassa IT, Elbert T: Structural and functional neuroplasticity in relation to traumatic stress. Current Directions in Psychological Science 2007, 16(6):321-325. 8. Onyut LP, Neuner F, Ertl V, Schauer E, Odenwald M, Elbert T: Trauma poverty and mental health among Somali and Rwandese refugees living in an African refugee settlement - an epidemiological study. Conflict and Health 2009, 3:6. 9. Schaal S, Elbert T: Ten years after the genocide: Trauma confrontation and posttraumatic stress in Rwandan adolescents. J Traum Stress 2006, 19:95-105. 10. Smith Fawzi MC, Pham T, Lin L, Nguyen TV, Ngo D, Murphy E, Mollica RF: The validity of posttraumatic stress disorder among Vietnamese refugees. J Traum Stress 1997, 10:101-108. 11. Lopes Cardozo B, Vergara A, Agani F, Gotway CA: Mental health social functioning and attitudes of Kosovar Albanians following the war in Kosovo. JAMA 2000, 284:569-577. 12. Shrestha NM, Sharma B, van Ommeren M, Regmi S, Makaju R, Komproe I, Shrestha GB, de Jong JT: Impact of torture on refugees displaced within the developing world: symptomatology among Bhutanese refugees in Nepal. JAMA 1998, 280:443-448. 13. Silove D, Sinnerbrink I, Field A, Manicavasagar V, Steel Z: Anxiety, depression and PTSD in asylum-seekers: associations with pre-migration trauma and post-migration stressors. Br J Psychiatry 1997, 170:351-357. 14. Elbert T, Rockstroh B, Kolassa IT, Schauer M, Neuner F: The influence of organized violence and terror on brain and mind - a co-constructive perspective. In Lifespan development and the brain: The perspective of biocultural co-constructivism. Edited by: Baltes P, Reuter-Lorenz P, Rösler F. Cambridge: University Press; 2006:326-349. 15. Kaldor M: New and Old wars: Organized Violence in a global era Stanford: Stanford University Press; 1999. 16. Neuner F, Schauer M, Karunakara U, Klaschik C, Robert C, Elbert T: Psychological trauma and evidence for enhanced vulnerability for PTSD through previous trauma in West Nile refugees. BMC Psychiatry 2004, 4(1):34. 17. Pham PN, Vinck P, Stover E: Returning home: forced conscription, reintegration, and mental health status of former abductees of the Lord’s Resistance Army in Northern Uganda. BMC Psychiatry 2009, 9:23. 18. Schauer E, Elbert T: The Psychological Impact of Child Soldiering. In Trauma Rehabilitation After War and Conflict: Community and Individual Perspectives. Edited by: Martz E. New York: Springer; 2010:311-360. 19. Corbin JN: Returning home: resettlement of formerly abducted children in Northern Uganda. Disasters 2008, 32(2):316-335. 20. Roberts B, Ocaka KF, Browne J, Oyok T, Sondorp E: Factors associated with post- traumatic stress disorder and depression amongst internally displaced persons in Northern Uganda. BMC Psychiatry 2008, 8(38):1-9. 21. Klasen F, Oettingen G, Daniels J, Post M, Hoyer C, Adams H: Posttraumatic resilience in former Ugandan child soldiers. Child Development 2010, 81(4):1096-1113. 22. Amone-P’Olak K: Coping with Life in Rebel Captivity and the Challenge of Reintegrating Formerly Abducted Boys in Northern Uganda. Journal of Refugee Studies 2007, 20(4):641-661. 23. Bayer CP, Klasen F, Adam H: Association of Trauma and PTSD Symptoms With Openness to Reconciliation and Feelings of Revenge Among Former Ugandan and Congolese Child Soldiers. JAMA 2007, 298(5):555-559. 24. Herman JL: Trauma and Recovery New York: Basic Books; 2003. 25. Foa EB: Posttraumatic stress diagnostic scale (PDS) Minneapolis: National Computer Systems; 1995. 26. Powell S, Rosner R, Butollo W, Tedeschi RG, Calhoun LG: Posttraumatic growth after war: a study with former refugees and displaced people in Sarajevo. J Clin Psychol 2002, 59(1):71-83. Pfeiffer and Elbert Conflict and Health 2011, 5:14 http://www.conflictandhealth.com/content/5/1/14 Page 6 of 7 27. Turner SW, Bowie C, Dunn G, Yule MSW: Mental health of Kosovan Albanian refugees in the UK. Br J Psychiatry 2003, 182:444-448. 28. Santa-Maria ML: Posttraumatic stress among Latin American immigrants: implication of family separations and disruption of attachments. PhD thesis Florida State University, College of Human Science; 2004. 29. Ertl V, Pfeiffer A, Saile R, Schauer E, Elbert T, Neuner F: Validation of a mental health assessment in an African conflict population. Psychol Assess 2010, 22(2):318-324. 30. Derogatis LR, Lipman RS, Rickels K, Uhlenhuth EH, Covi L: The Hopkins Symptom Checklist (HSCL): a self-report symptom inventory. Behavioral Science 1974, 19(1):1-15. 31. Mollica RF, Wyshak G, de Marneffe D, Khuon F, Lavelle J: Indochinese versions of the Hopkins Symptoms Checklist-25: a screening instrument for the psychiatric care of refugees. Am J Psychiatry 1987, 144(4):497-500. 32. Mollica RF, Wyshak G, de Marneffe D, Tu B, Yang T, Khuon F, Coelho RC, Lavelle J: Hopkins Symptoms Checklist 25 (HSCL-25): manual Cambodian, Laotian and Vietnamese versions. Torture 1996, 6(Suppl 1):35-42. 33. Carlson EB, Rosser-Hogan R: Mental health status of Cambodian refugees ten years after leaving their homes. Am J Orthopsychiatry 1993, 63:223-231. 34. Hinton WL, Du N, Chen YC, Tran CG, New TB, Lu FG: Screening for major depression in Vietnam refugees: a validation and comparison of two instruments in a health screening population. JGIM 1994, 9:202-206. 35. van Willigen LH, Hondius AJ, van der Ploeg HM: Health problems of refugees in the Netherlands. Trop Geogr Med 1995, 47:118-124. 36. Lie B: A 3-year follow-up study of psychosocial functioning and general symptoms in settled refugees. Acta Psychiatr Scand 2002, 106:415-425. 37. Gerritsen AAM, Bramsen I, Devillé W, van Willigen LHM, Hovens JE, van der Ploeg HM: Health and health care utilisation among asylum- seekers and refugees in the Netherlands: design of a study. BMC Public Health 2004, 4(7). 38. Mollica RF, McInnes K, Sarajlic N, Lavelle J, Sarajlic I, Massagli MP: Disability associated with psychiatric comorbidity and health status in Bosnian refugees living in Croatia. JAMA 1999, 282(5):433-439. 39. Bolton P, Neugebauer R, Ndogoni L: Prevalence of depression in rural Rwanda based on symptom and functional criteria. Journal of Nervous and Mental Disease 2002, 190(9):631-637. 40. Flanagan AY: Three ways of translating instruments in cross-cultural research. E-Research Newsletter - Creating a Community Between Cross- Cultural Practitioners and Researchers 1999, 1. 41. Annan J, Blattman C: Survey of War affected Youth Kampala: United Nations Children Fund (UNICEF); 2006. 42. Derluyn I, Broekaert E, Schuyten G, de Temmerman E: Post-traumatic stress in former Ugandan child soldiers. Lancet 2004, 363(9412):861-863. 43. Basoglu M, Paker M, Paker O, Ozmen E, Marks I, Incesu C: Psychological effects of torture: a comparison of tortured with nontortured political activists in Turkey. Am J Psychiatry 1994, 151(1):76-81. 44. Moisander PA, Edston E: Torture and its sequel - a comparison between victims from six countries. Forensic Sci Int 2003, 137(2-3):133-140. 45. Mollica RF, McInnes K, Poole C, Tor S: Dose-effect relationships of trauma to symptoms of depression and post-traumatic stress disorder among Cambodian survivors of mass violence. Br J Psychiatry 1998, 173:482-488. 46. Breslau N, Davis G, Andreski P, Peterson E: Traumatic events and posttraumatic stress disorder in an urban population of young adults. Arch Gen Psychiatry 1991, 48:216-222. 47. Kessler RC, Sonnega A, Hughes M, Nelson CB: Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995, 52:1048-1060. 48. Catani C, Jacob N, Schauer E, Mahendran K, Neuner F: Family violence war and natural disasters: a study of the effect of extreme stress on children’s mental health in Sri Lanka. BMC Psychiatry 2008, 8:33. 49. Kolassa IT, Ertl V, Eckart C, Glöckner F, Kolassa S, Papassotiropoulos A, de Quervain DJ, Elbert T: Association study of trauma load and SLC6A4 promoter polymorphism in PTSD: evidence from survivors of the Rwandan genocide. J Clin Psychiatry 2010, 71(5):543-547. 50. Scholte WF, Olff M, Ventevogel P, de Vries GJ, Jansveld E, Cardozo BL: Mental health symptoms following war and repression in eastern Afghanistan. JAMA 2004, 292(5):585-593. 51. Elbert T, Weierstall R, Schauer M: Fascination Violence - on mind and brain of man hunters. Eur Arch of Psychiatr Clin Neurosci 2010, 260:100-105. 52. Weierstall R, Schalinski I, Crombach A, Hecker T, Elbert T: When combat prevents PTSD symptoms - results from a survey with former child soldiers in Northern Uganda. Submitted for publication; 2011. doi:10.1186/1752-1505-5-14 Cite this article as: Pfeiffer and Elbert: PTSD, depression and anxiety among former abductees in Northern Uganda. Conflict and Health 2011 5:14. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit Pfeiffer and Elbert Conflict and Health 2011, 5:14 http://www.conflictandhealth.com/content/5/1/14 Page 7 of 7 . RESEARCH Open Access PTSD, depression and anxiety among former abductees in Northern Uganda Anett Pfeiffer * and Thomas Elbert Abstract Background: The population in Northern Uganda has been exposed. people, mainly women and children, marched into the towns and camps seeking shelter, for fear of abduction if they remained in their homes. ThemajorityofIDPs,currentlysettledinthecoun- try’ s northern. suffering and make them functional again for their personal daily life tasks as well as in the interest of a society trying to recover from years of insurgencies. As an interesting tendency that